Thursday, October 29, 2009

Nagesh Simha knows about pain. He has had three kidney transplants, one of which led to such severe complications that he had to have both hips replaced. But when he's not a patient, he's a surgeon, supervising a cancer hospice in Bangalore - where he sees patients in what he calls the "catastrophic pain" that frequently accompanies the disease.

As a patient, Dr. Simha knows what opiates can do: the blessed relief from pain that cheap, simple drugs such as morphine can provide. And as a palliative-care physician, he knows that tragically few Indians who need that relief will get it.

"It's pathetic," said Dr. Simha, president-elect of the Indian Association of Palliative Care. "If there was any political will, this thing could be fixed in a week, and fixed very cheaply."

Drugs to control the severe pain of people with diseases such as cancer cost as little as two cents for a 10-milligram tablet, and India is one of the world's major producers. However, nearly all those drugs are exported. Due to a combination of bad laws, bungled bureaucracy and poor physician training, up to seven million Indians each year needlessly suffer acute pain, according to a report released yesterday by Human Rights Watch.

"India has many well-trained, sophisticated doctors at cancer hospitals who could easily treat pain but they don't have access to morphine and/or they have had no training on pain management," said Diederik Lohman, author of the report.

Eighteen of 29 main cancer centres do not have personnel trained to administer morphine and other strong pain medications. Morphine is available in even fewer AIDS-treatment centres, TB facilities and primary-health centres. Neither pain management nor palliative care is taught in the standard Indian medical school curriculum.

The report provokes the question of whether, with so many critical primary health- care problems, palliative care is a luxury India can afford to worry about. Mr. Lohman countered that the difference is that the pain problem could be quickly and easily solved. "You can't say that until malnutrition is solved in India you're not going to do anything else ... It would take very little to make morphine available and train doctors how to use it."

India's failure to provide pain management originates in excessively complex drug laws - which reflect, in part, a worldwide paranoia about the use of opiates, Mr. Lohman said - but here the problem has been exacerbated by a vast, slow-moving bureaucracy. In 1985, India introduced legislation to control illicit opiate use, but the law inadvertently made it extremely difficult for legitimate users to get access. Morphine treatment virtually disappeared overnight. Finally, in 1998, the central government drafted new regulation and suggested states use it, but two-thirds have yet to do so.

Because doctors are not trained in using the drugs, they do not create any demand for change, and continue to hold misconceptions about the potential for addiction and misuse of morphine.

Patients told Human Rights Watch that doctors ignored their pain, dismissed it as inevitable or offered acetaminophen; doctors described avoiding patients with pain because they had no way to help. Dr. Nagesh said those doctors were a minority - most simply had no concept of how great their patients suffering was, or how easily they could mitigate it. "The biggest obstacle is the medical profession itself.

Tuesday, October 27, 2009

The rationale behind torture is that pain will make the guilty confess, but a new study by researchers at Harvard University finds that the pain of torture can make even the innocent seem guilty.

Participants in the study met a woman suspected of cheating to win money. The woman was then "tortured" by having her hand immersed in ice water while study participants listened to the session over an intercom. She never confessed to anything, but the more she suffered during the torture, the guiltier she was perceived to be.

The research, published in the "Journal of Experimental Social Psychology," was conducted by Kurt Gray, graduate student in psychology, and Daniel M. Wegner, professor of psychology, both in Harvard's Faculty of Arts and Sciences.

"Our research suggests that torture may not uncover guilt so much as lead to its perception," says Gray. "It is as though people who know of the victim's pain must somehow convince themselves that it was a good idea -- and so come to believe that the person who was tortured deserved it."

Not all torture victims appear guilty, however. When participants in the study only listened to a recording of a previous torture session -- rather than taking part as witnesses of ongoing torture -- they saw the victim who expressed more pain as less guilty. Gray explains the different results as arising from different levels of complicity.

"Those who feel complicit with the torture have a need to justify the torture, and so link the victim's pain to blame," says Gray. "On the other hand, those distant from torture have no need to justify it and so can sympathize with the suffering of the victim, linking pain to innocence."

The study included 78 participants: half met the woman who was apparently tortured (actually a confederate of the experimenters who was, of course, not harmed at all), and half did not. Participants were told that the study was about moral behavior, and that the woman may have cheated by taking more money than she deserved. The experimenter suggested that a stressful situation might make a guilty person confess, so participants listened for a confession over a hidden intercom as she was subjected to the sham "torture."

The confederate did not admit to cheating but reacted to having her hand submerged in ice water with either indifference or with whimpering and pleading. Participants who had met her rated her as more guilty the more she suffered. Those who did not meet her rated her as more guilty when she felt less pain.

Gray suggests that these results offer an explanation for the debate swirling around torture.

"Seeing others in pain can perpetuate ideological differences about the justifiability of torture," says Gray. "Those who initially advocate torture see those harmed as guilty, unlike those who initially reject torture and its methods."

The findings also shed light on the Abu Ghraib scandal, where prison guards tortured Iraqi detainees. Prison guards, who are close to the suffering of detainees, see detainees as more guilty the more they suffer, unlike the more distant general public.

The case is still open on whether torture actually makes victims more likely to tell the truth. This research suggests instead that the mere fact that someone was tortured leads observers to think that the truth was found.

Researchers at Harvard University have discovered that our experience of pain depends in part on whether we think someone caused the pain intentionally. Participants in a study who believed they were getting an electrical shock from another person on purpose, rather than accidentally, rated the shock as more painful than those receiving the same shock thinking it was an accident. Participants seemed to get used to shocks that were delivered unintentionally, but those given on purpose had a fresh sting every time.

The research, published in the current issue of Psychological Science, was led by Kurt Gray, a graduate student in psychology, along with Daniel Wegner, professor of psychology.

It has long been known that our own mental states can alter the experience of pain, but these findings suggest that our perceptions of the mental states of others can also influence how we feel pain.

"This study shows that even if two harmful events are physically identical, the one delivered with the intention to hurt actually hurts more," says Gray. "Compare a slap from a friend as she tries to save us from a mosquito versus the same slap from a jilted lover. The first we shrug off instantly, while the second stings our cheek for the rest of the night."

The study's authors suggest that intended and unintended harm cause different amounts of pain because they differ in meaning.

"From decoding language to understanding gestures, the mind distills meaning from our social environment," says Gray. "An intended harm has a very different meaning from an accidental harm."

The study included 48 participants who were paired up with a partner who could administer to them either an audible tone or an electric shock. In the intentional condition, participants received a shock when their partner chose the shock option. In the unintentional condition, participants received a shock when their partner chose the tone option. Thus, in this condition, they only received a shock when their partner did not intend them to receive one. The computer display ensured that participants both knew their partner's choice and that a shock would be coming, to ensure the shock was not more surprising in the unintentional condition.

Despite identical shock voltage between conditions, those in the intentional condition rated the shocks as significantly more painful. Furthermore, those in the unintentional condition habituated to the pain, rating them as decreasingly painful, while those in the intentional condition continued to feel the full sting of pain.

Gray suggests that it may be evolutionarily adaptive for this difference in meaning to be represented as different amounts of pain.

"The more something hurts, the more likely we are to take notice and stop whatever is hurting us," he says. "If it's an accidental harm, chances are it's a one-time thing, and there's no need to do anything about it. If it's an intentional harm, however, it may be the first of many, so it's good to take notice and do something about it. It makes sense that our bodies and brains might amplify our experience of pain when we know that the pain could signal threats to our survival."

These findings speak to how people experience pain and negative life events. If negative events are seen as intended, they may hurt more. This helps to explain why torture is so excruciating — not only are torture techniques themselves exceptionally painful, but it's the thought that counts — and makes torture hurt more than mere pain.

On the other hand, if negative events are seen as unintended, they may hurt less. This may explain, in part, why people in abusive relationships sometimes continue to stay in them. By rationalizing that an abusive partner did not intend harm, some victims may reduce their experience of pain, which could make them less likely to leave the relationship and escape the abuse.

With Canada on the brink of one of its largest-ever vaccination drives, a group of academics and doctors is urging health-care workers to make flu and other shots less painful for children, suggesting it is actually "unethical " for them to ignore the sting of injections.

Many doctors and parents believe a needle is nothing to fret about, with the hurt lasting only a moment and leaving no long-term effects, the researchers acknowledge in a series of medical-journal papers just published.

Using one of several possible pain-reduction techniques, however, could help avert needle phobias that affect as much as 10% of the population, last years and undermine vaccination campaigns, they argue.

Those methods -- from anesthetic cream applied to the skin to simply giving babies sugar water -- are seldom employed now, the panel says in the journal Clinical Therapeutics.

"The attitude is, 'It's only pain -- what's the big deal?' " said Anna Taddio, a pharmacy professor at the University of Toronto and lead author of the papers. "But it actually is when you start figuring out what all the costs of it are. It means someone is not going to donate blood ... and it means that person doesn't go to see the doctor, doesn't go to see the dentist because they don't want to be poked," she said. "They're probably sicker as a group of people."

The issue is becoming more pressing, given that Canadian children are receiving a constantly expanding range of vaccines --as many as 20 shots by age five -- while uptake on immunization is dropping, the journal articles argue.

Not everyone is convinced of the need for widespread action, though. Pain in immunization is undoubtedly a serious issue for a "subset" of children who could benefit from pain-reduction methods, but they are likely the exception, said Dr. Peter Nieman, a Calgary pediatrician. "For the majority of kids I've seen, it's a trade-off," he said. "On the one hand, nobody in their right mind would say, 'I love needles,' but on the other hand, the pain you put up with is a small price to pay for the benefit you get."

Nevertheless, Prof. Taddio's group, including pharmacists, physicians and pain researchers, is developing a formal practice guideline around vaccine-pain reduction that it hopes the Canadian Pediatric Society will adopt for its members soon.

There is also a movement to have pain reported as one of the adverse side effects of vaccine injections, which might encourage pharmaceutical companies to produce vaccines that hurt less, Prof. Taddio said. Some formulations are already less painful than others, a function of the chemicals used and how they interact with human tissue.

As a physician and pharmacologist in the emergency department of a London, Ont., hospital, Dr. Michael Rieder says he sees the impact of pain-induced needle fear "all the time," with older children and even teenagers recoiling at the approach of a hypodermic, whether it is to draw blood or inject local anesthetic.

"One of the biggest problems in pediatric acute care is fear of needles," he said. "If you have to draw blood and the child is struggling and fighting because they're afraid of a needle, it's not such an easy thing to do."

The group's review of evidence cites studies that suggest 90% of toddlers and 50% of school-age children experience severe distress during vaccination, with some evidence that early bad experiences can condition bodies to be more sensitive to pain in future.

About one in 10 people is estimated to have full-blown needle phobia, and 25% of adults to have significant fears, prompting them to avoid dental visits, fail to donate blood and neglect insulin injections, the researchers say.

In one study of 12,000 people, only 12% agreed to undergo a free flu vaccine, and virtually all of them chose a nasal spray instead of a needle, many of them citing the pain of injection for their decision.

In fact, recent polls suggest that only a third of Canadians plan to get the H1N1 vaccine, and Prof. Taddio believes memories of childhood immunization pain are likely a reason why some will pass on the shot.

To reduce needle pain, apply topical anesthetic creams; comfort babies by having them breast-feed or suck on sugar water during the shot; and simply distract the child. Doctors and others should also give needles without aspirating, a process designed to ensure they are not injecting vaccine into a blood vessel, Prof. Taddio said. Aspiration prolongs the pain and is not necessary, she said.

Thursday, October 22, 2009

If your ears are still ringing from that last Metallica concert, scientists can't help you--but they may have figured out what's going on in your head. A type of small neuron in the inner ear, it seems, may help process painfully loud sounds. The discovery solves a 70-year-old mystery about what these neurons do--and may deepen understanding of hearing loss and impairment.

Humans and other mammals owe their hearing to a forest of hairlike cells in the inner ear. As sound waves move into the ear, the hair cells sway along, and their motion releases electrical and chemical signals that the brain interprets as sound.

Two kinds of neurons transmit those signals. Type I is the standard: It makes up 90% to 95% of all neurons in the inner ear and tells the brain about a sound's frequency, volume, and timing--all the ingredients of hearing as we know it. The remaining 5% of the neurons are type II, which were first described in 1937 and are smaller and harder to study. In fact, just a single study has reported success in connecting a type II neuron to an electrode, which is the main method for studying hearing cells.

Hearing researcher Paul Fuchs and his colleagues at the Johns Hopkins University School of Medicine in Baltimore, Maryland, came up with a different way to isolate the elusive neurons. Instead of trying to find them within an intact ear, they dissected the inner ears of rats. During a window of only a few hours before the tissue samples died, the researchers tracked down the type II neurons, hooked them up to electrodes, and recorded what they did in the presence of a chemical that provokes the same reaction as sound in hearing cells.

The team found that the type II neurons were indeed reacting to sound but only to very loud sound. They were also especially sensitive to ATP, a neurotransmitter associated with painful stimuli and tissue damage, among many other functions. Together, these observations suggest that the type II neurons are "a specialized pathway for very loud sound," says Fuchs, whose group reports its findings tomorrow in Nature.

A "pain pathway" role for type II neurons may also help explain why hearing loss is often accompanied by increased sensitivity to loudness and pain. By sensitizing the ear after damage has occurred, the type II fibers may be working to prevent future damage, Fuchs says.

"In one fell swoop, this study increased what we know by an order of magnitude," says Jonathan Ashmore, a cochlear physiologist at University College London. But he notes that the neurons' sensitivity to ATP could point to a different role in the ear. They may help the brain monitor whether the cochlea's hair cells are working properly or have been damaged, without actually processing the traumatic sound. In either case, the technique opens an exciting door, adds Ashmore. "We know almost nothing about the underlying neuroscience of hearing loss or impairments like tinnitus."

Wednesday, October 21, 2009

Neck pain is common, disabling and costly. Electrotherapy is an umbrella term that covers a number of therapies that aim to reduce pain and improve muscle tension and function.

This updated review included 18 small trials (1043 people). The results of the trials could not be pooled because they examined different populations, types and doses of electrotherapy, and comparison treatments and measured slightly different outcomes.

We cannot make any definitive statements about the efficacy of electrotherapy for neck pain because of the low or very low quality of the evidence for each outcome, which in most cases, was based on the results of only one trial.

For patients with acute neck pain, TENS possibly relieved pain better than electrical muscle stimulation, not as well as exercise and infrared and as well as manual therapy and ultrasound. There was no additional benefit when added to infrared, hot packs and exercise, physiotherapy or a combination of a neck collar, exercise and pain medication.

For patients with acute whiplash, iontophoresis was no more effective than no treatment, interferential current or a combination of traction, exercise and massage for relieving neck pain with headache; pulsed electro-magnetic field was more effective than 'standard care'.

For patients with chronic neck pain, TENS possibly relieved pain better than placebo and electrical muscle stimulation, not as well as exercise and infrared and possibly as well as manual therapy and ultrasound; pulsed electro-magnetic field was possibly better than placebo, galvanic current, and electrical muscle stimulation. Magnetic necklaces were no more effective than placebo for relieving pain; there was no additional benefit when electrical muscle stimulation was added to either mobilisation or manipulation.

While over half of the trials were assessed as having a low risk of bias, seven of them did not describe how their participants were randomised, eight did not conceal the treatment assignment, and 12 did not control co-interventions. The trials were very small, with a range of 16 to 336 participants. Sparse and imprecise data mean the results cannot be generalized to the broader population and contributes to the reduction in the quality of the evidence, which was low or very low for all results. Therefore, further research is very likely to change the results and our confidence in them.

Tuesday, October 20, 2009

I am pleased to announce the 2009–2010 Global Year Against Musculoskeletal Pain. This IASP-sponsored campaign will draw attention to the disabling pain experienced by people around the world suffering from musculoskeletal disorders. Built around the theme of "When Moving Hurts: Assess, Understand, Take Action," this vital initiative calls upon each of us to provide a voice to those with musculoskeletal pain by:

Educating pain researchers as well as health care professionals globally who see the issues associated with musculoskeletal pain first-hand in their interactions with patients.

Increasing awareness of musculoskeletal pain among government officials, members of the media, and the general public worldwide.

Encouraging government leaders, research institutions, and other key decision-makers to support more research, thus producing more effective and accessible treatment methods and outcomes for people with musculoskeletal pain.

Throughout the campaign, which will run through late October 2010, IASP's members and chapters will organize meetings, symposia, patient-education events, publications, and many other efforts exploring different aspects of musculoskeletal pain. In addition, IASP and its chapters will sponsor media efforts highlighting some of the challenges posed by musculoskeletal pain.

I encourage you to get involved in any such activities planned in your area. Whether you help to plan and organize an event, deliver a talk related to musculoskeletal pain, or attend a meeting to show your support, your participation is essential to the success of the Global Year Against Musculoskeletal Pain. Please contact your local IASP chapter, or the IASP secretariat office at iaspdesk@iasp-pain.org, for more information on scheduled activities in your area and other ways to get involved.

Be sure to visit the Global Year web pages regularly, where you will find a series of Fact Sheets focusing on more than 20 topics related to musculoskeletal pain—furnished in English, Arabic, Chinese, French, Spanish, and other languages. The fact sheets, campaign posters, and other resources are available to all at no cost. You can also register to receive Global Year Updates (via email) with the latest news and campaign resources.

Monday, October 19, 2009

In the first tightly controlled trial to look at both alternative therapies, there was no benefit to their use for pain or stiffness.

All 45 patients tested a copper bracelet, two different magnetic wrist straps, and a demagnetised version.

An arthritis charity said people should not waste their money on the therapies.

Study leader Stewart Richmond, a research fellow in the Department of Health Sciences, said there had only been one other randomised controlled trial - comparing the treatment with placebo - on copper bracelets and that was done in the 1970s.

The market - particularly in magnetic devices which can cost £25 and £65 for the wrist straps - is worth billions of dollars worldwide.

In the trial, 45 people aged 50 or over, who were all diagnosed as suffering from osteoarthritis wore each of the four devices in a random order over a 16-week period.

They were all ineffective in terms of pain, stiffness and physical function, the researchers reported in the journal Complementary Therapies in Medicine.

"It appears that any perceived benefit obtained from wearing a magnetic or copper bracelet can be attributed to psychological placebo effects," said Mr Richmond.

"People tend to buy them when they are in a lot of pain, then when the pain eases off over time they attribute this to the device.

"However, our findings suggest that such devices have no real advantage over placebo wrist straps that are not magnetic and do not contain copper."

Friday, October 16, 2009

If you thought the placebo effect was all in the mind, think again. Scientists have solved the mystery of why some people benefit from remedies that do not contain any active pain-relief ingredients.

Research suggests that placebos work, in part, by blocking pain signals in the spinal cord from arriving at the brain in the first place.

When patients expect a treatment to be effective the brain area responsible for pain control is activated, causing the release of natural endorphins.

The endorphins send a cascade of instructions down to the spinal cord to suppress incoming pain signals and patients feel better whether or not the treatment had any direct effect.

The sequence of events in the brain closely mirrors the way opioid drugs, such as morphine, work — adding weight to the view that the placebo effect is grounded in physiology.

The finding strengthens the argument that many established medical treatments derive part of their effectiveness from the patients' expectation that the drugs will make them better.

The latest studies on antidepressants suggest that at least 75 per cent of the benefit comes from the placebo effect. GPs also observe that patients report feeling better only days after being prescribed antidepressants, even though the direct effects take several weeks to kick in.

In the study, published today in the journal Science, the spinal cords of 15 healthy volunteers were scanned using functional magnetic resonance imaging (MRI). The scan homed in on an area called the dorsal horn, which transmits pain signals coming up through the spinal cord into the pain-related areas in the brain.

During the scan, the volunteers received laser "pinpricks" to their hands. The volunteers were told that a pain-relief cream had been applied to one of their hands and a control cream to the other. But unknown to the volunteers, an identical control cream was administered to both hands.

When people believed that they had received the active cream, they reported feeling 25 per cent less pain and showed significantly reduced activity in the spinal cord pathway that processes pain.

Previously, it has been shown that placebo causes the release of natural opioids in areas of the brain involved in pain control, such as the rostral anterior cingulate cortex. However, it was not known whether the natural opioids acted on the spinal cord in the same way as artificial painkillers or whether they simply changed people's tolerance or interpretation of pain.

"We've shown that psychological factors can influence pain at the earliest stage of the central nervous system, in a similar way to drugs like morphine," said Falk Eippert, of the University Medical Centre Hamburg-Eppendorf, who led the study.

Until now, the difficulty of obtaining MRI images of the spinal cord, because of its small size and its being surrounded by airways and pulsating arteries, prevented this question from being addressed. However, advances in image processing allowed the Hamburg team to obtain high resolution scans of the region.

The advance in imaging techniques is likely to have important applications for drug development.

Pharmaceutical companies are working to develop new anaesthetic drugs that target the pain pathways in the spinal cord. Being able to image this area of the body provides a direct way of testing whether the drugs are working as intended.

Wednesday, October 14, 2009

This classroom will provide you with information on different typesof pain, how to prevent painful conditions and how to management ofall types of pain

Chronic Pain Self ManagementSelf-management programs for patients with chronic health conditionsassist patients by providing them with education to help them managetheir conditions. Here we will provide you with an overview of theChronic Pain Self Management program.

Pain SyndromesFind out about over 40 different pain conditions with links availableto additional information.

How to Talk to your PhysicianShows you real life examples of how to communicate with yourphysician and how to make the best use physician visit.

Patient ResourcesWelcome to the Pain Resource Centre, the one place to get paininformation.

Pain PreventionLearn how to prevent painful conditions with preventative advice.

People often eat food to feel better, but researchers have found that eating chocolate or drinking water can blunt pain, reducing a rat's response to a hot stimulus. This natural form of pain relief may help animals in the wild avoid distraction while eating scarce food, but in modern humans with readily available food, the effect may contribute to overeating and obesity.

The study, published in the Journal of Neuroscience by authors Peggy Mason, PhD, professor of neurobiology, and Hayley Foo, PhD, research associate professor of neurobiology at the University of Chicago, is the first to demonstrate that this powerful painkilling effect occurs while the animals are ingesting food or liquid even in the absence of appetite.

"It's a strong, strong effect, but it's not about hunger or appetite," Mason said. "If you have all this food in front of you that's easily available to reach out and get, you're not going to stop eating, for basically almost any reason."

In the experiments, rats were given either a chocolate chip to eat or had sugar water or regular water infused directly into their mouth. As the rat swallowed the chocolate or fluid, a light-bulb beneath the cage was switched on, providing a heat stimulus that normally caused the animal to lift its paw off the floor. Mason and Foo found that rats were much slower to raise their paw while eating or drinking, compared to tests conducted while they were awake, but not eating.

Surprisingly, the researchers found no difference in the delayed paw- lift response between when the rat was eating chocolate and when it was drinking water, despite previous research indicating that only sugary substances were protective against pain.

"This really shows it has nothing to do with calories," Mason said. "Water has no calories, saccharine has no sugar, but both have the same effect as a chocolate chip. It's really shocking."

Mason and Foo then repeated the heat test as the rats were given quinine, a bitter drink that causes rats to make an expression called a gape that's akin to a child's expression of "yuck." During quinine administration, the rats reacted to heat as quickly as when not eating, suggesting that a non-pleasurable food or drink fails to trigger pain relief.

The context of ingesting was also important to whether eating or drinking blunted pain, the researchers found. When rats were made ill by a drug treatment, eating chocolate no longer delayed their response. However, drinking water still caused a reduced pain response, indicating that drinking water was considered a positive experience while ill.

By selectively inactivating a region in the brainstem called the raphe mangus – an area previously shown to blunt pain during sleep and urination – Mason and Foo were able to remove the effect of drinking water on the rat's pain response. The brainstem controls subconscious responses such as breathing and perspiration during exercise.

"You're essentially at the mercy of your brainstem, and the raphe magnus is part of that," Mason said. "It tells you, 'you're going to finish eating this, whether you like it or not,' just like you sweat while running whether you like it or not."

In the wild, Mason said, rats and other animals would not want to be distracted during the rare but important times that they were able to eat or drink. Therefore, the activation of the raphe magnus during eating or drinking would allow the rat to filter out distractions until their meal was completed. For obvious reasons, this natural pain relief would be activated when an animal is eating or drinking something pleasurable, but not when it tastes something that could be toxic or harmful.

Don Katz, an associate professor of psychology and neuroscience at Brandeis University who studies taste, said that Mason and Foo's paper brings together two systems – taste and pain – that are usually studied separately.

"They're saying the purpose of the taste system is to give the animal a cue that helps it decide what stimulus they should or shouldn't pay attention to," Katz said. "This shows there is a whole region there to enable the animal to keep eating."

Mason believes that this effect is also present in humans (studies by other labs have observed similar pain reduction in infants receiving sugar water during a booster shot), but that it has detrimental effects in modern society given our ready access to large quantities of pleasurable and fattening foods. Opening up a bag of chips could activate the brainstem such that you don't stop eating until the bag is empty, even while realizing that such behavior is bad for you.

"We've gotten a lot more overweight in last 100 to 150 years," Mason said. "We're not more hungry; the fact of the matter is that we eat more because food is readily available and we are biologically destined to eat what's readily available."

But the painkilling effect can be turned to our advantage, Mason said, perhaps as a replacement for the practice of using candy to calm children – or even adults – in the doctor's office.

"Ingestion is a painkiller but we don't need the sugar," Mason said. "So replace the doctor's lollipop with a drink of water."

The research was funded by a grant from the National Institute on Drug Abuse and the Women's Council of the Brain Research Foundation. The paper, "Analgesia accompanying food consumption requires ingestion of hedonic foods," appears in the October 14th issue of the Journal of Neuroscience.

Monday, October 12, 2009

Children treated for arm fractures with ibuprofen had their pain reduced just as effectively as a combination of acetaminophen and codeine (Tylenol 3), with fewer adverse effects, in a randomized, double-blind trial.

The study tested ibuprofen, sold as Advil, Motrin and other brands, against acetaminophen plus codeine — a combo called Tylenol No. 3 that is also sold in generic form.

"The children on ibuprofen did better," said the study leader, Dr. Amy Drendel of the Medical College of Wisconsin in suburban Milwaukee. "They were more likely to play, they ate better and they had fewer adverse effects," she said.

Among those kids taking ibuprofen, 29.5% reported an adverse effect. Among those taking the codeine-laced drug, 50.9% reported an adverse effect. Such reactions included nausea, vomiting, drowsiness, dizziness and constipation.

The results do not mean that ibuprofen beats acetaminophen for everyday pain relief in children or anyone else.

The study tested a specific use — pain in the first three days after a broken arm — and the acetaminophen was combined with the narcotic codeine, not tested alone.

Broken arms are one of the most common childhood injuries, with one study estimating that 18 percent of children will have a fracture some time during the first nine years of life.

Researchers randomly assigned 336 children ages 4 to 18 to go home with liquid versions of either ibuprofen or the acetaminophen-codeine combo after being treated for a broken arm at Children's Hospital of Wisconsin. Neither the children, parents nor the doctors knew who received what treatment until the study ended.

“It’s tough enough as a child to have a broken arm without also having to deal with pain,” said Dr. Drendel. “It’s good for both emergency physicians and parents to have pain-management options that can help get a child back to playing as quickly as possible.”

Having gone through five significant operations, including one to remove my entire diseased colon and another to cut out my cancerous prostate, I think I can safely state that pain falls into two broad categories: the kind you can articulate, and pain that is beyond words.

If you can tell an E.M.T., a nurse or a doctor where it hurts and how much, that is generally a good sign. But what interests me even more is the pain that can't be articulated. Fortunately, I've experienced this only twice.

The first time came in 1984, when I had my colon taken out. I had been taken back to my room after surgery, one-quarter awake and feeling as if I had just tumbled over Niagara Falls in a barrel. The orderlies and nurses wheeled the gurney against my hospital bed, then started to move me. That was when I became half-awake.

Even though they were tugging me just a few inches, my body pulsed with the worst pain that I had felt in my life. And when it seemed to me that the half-dozen or so tubes snaking from my body were about to be ripped out because they were tangled at the foot of my bed, I tried to shout. But all that came out, I think, was, "Uh-uh-uh." Mercifully, once I slumped onto my bed, I heaved a sigh and went to sleep.

When I had my prostate out in 2008, I almost fainted when a new resident tried to remove one of my drains. Instead of giving it a firm yank, she waggled it inside my body as if she were whipping up cotton candy. I became dizzy, broke into a cold sweat and nearly threw up. She finally left and got help.

I wouldn't have chosen to be in those two situations, but each one granted me insight into myself and into the nature of pain.

In each case, I was humbled by pain that to me seemed to transcend the basic medical scale of 1 (mildest) to 10 (most severe). And pain is a path to humility. When it hurts just to wriggle up in bed, elbows digging into the mattress for support, you generally don't think of yourself as sitting atop the food chain.

And pain is a teacher. More than ever, I understand how abhorrent it is to inflict pain. I have learned to distinguish between mere discomfort and pain that can't be tolerated. And tough-guy popular culture — oh, great, ultimate fighting on Spike TV — doesn't impress me at all.

I have no patience these days with the Nietzschean cliché, "That which does not kill us makes us stronger." I've found that the deepest pain holds no meaning. It is not purifying. It is not ennobling. It does not make you a better human being. It just is.

All the worst pain does is reduce us to our most primal animal. We want it to stop. We want to survive. It short-circuits any sense of self, diminishes us to a bundle of biological reflexes.

Right after the radical open surgery to remove my prostate, I felt like one big post-op throb of pain. The morphine drip was my new best pal. It didn't take long, though, for discrete fiefs of ache and twinge to make themselves known: catheter burn (complemented by the occasional bladder spasm), sore and swollen testicles and the subtle attack of hospital-bed back.

But oddly enough, those sensations were almost pleasant — distractions from my wounded gut. The abdominal incision was raw and tender, but that didn't stop me from fingering it, searching for different notes of discomfort on the xylophone of the 25 metal staples that held me together.

I've been surprised by the degree of pain you can become used to. Before I had my colon out, my stomach hurt constantly from ulcerative colitis, and I bled a lot from my rectum. It wasn't until I was recovering that I realized how sick I had been.

One side effect of all these operations is that common day-in-and-day-out bumps and bruises don't get much of a rise out of me. Stubbed toes and headaches, spider bites and bee stings? Whatever. The bracing prickle of alcohol sloshed onto a cut or a scrape actually feels pretty good to me. And after all the siphoning, and replenishing, of my blood over the years, I don't flinch at needles.

We don't like to talk about pain — are somehow shamed by it and try to shrug it off. We're told to play through pain or, even, to pray through it. We revere our stoic American archetypes, like the Wild West gunslinger riddled by half a dozen slugs of lead who swears, "Aw heck, Doc, it's only a scratch."

One of the stupidest things I've ever done was not take my pain medication after that surgery in 1984. I was raised in a tight-lipped rural culture in which even aspirin was suspect, and I was taught that real men embraced their pain as if it were their destiny. It was supposed to be better to sweat through pain-induced insomnia at 3 in the morning than give in to the terrible temptation to take a pill that would let you sleep.

Well, enough with that. Pain is a crucial part of our medical tales. It needs to be articulated, then confronted — even if, sometimes, the pain is beyond words.

Dana Jennings is a reporter at The New York Times. His postings on coping with prostate cancer appear each week at nytimes.com/well.

A relaxation-type CD, asking children to imagine themselves in scenarios like floating on a cloud led to dramatic improvements in abdominal pain.

The US researchers said the technique worked particularly well in children as they have such fertile imaginations.

It has been estimated that frequent stomach pain with no identifiable cause affects up to one in five children.

The research, published in the journal Pediatrics, follows on from studies showing hypnosis is an effective treatment for a range of conditions known as functional abdominal pain, which includes things like irritable bowel syndrome.

In this study, the children had 20 minute sessions of "guided imagery" - a technique which prompts the subject to imagine things which will reduce their discomfort.

One example is letting a special shiny object melt into their hand and then placing their hand on their belly, spreading warmth and light from the hand inside the tummy to make a protective barrier inside that prevents anything from irritating the belly

The researchers, from the University of North Carolina and Duke University Medical Center, said a lack of therapists led them to the idea of using a CD to deliver the sessions.

In all 30 children aged between six and 15 years took part in the study - half of whom used the CDs daily for eight weeks and the rest of whom got normal treatment.

Among those who had used the CDs, 73.3% reported that their abdominal pain was reduced by half or more by the end of the treatment course compared with 26.7% in the standard care group.

In two-thirds of children the improvements were still apparent six months later.

Sunday, October 11, 2009

The purpose of this Funding Opportunity Announcement (FOA), "Mechanisms, Models, Measurement, & Management in Pain Research," is to inform the scientific community of the pain research interests of the various Institutes and Centers (ICs) at the National Institutes of Health (NIH) and to stimulate and foster a wide range of basic, clinical, and translational studies on pain as they relate to the missions of these ICs.

New advances are needed in every area of pain research, from the micro perspective of molecular sciences to the macro perspective of behavioral and social sciences. Although great strides have been made in some areas, such as the identification of neural pathways of pain, the experience of pain and the challenge of treatment have remained uniquely individual and unsolved. Furthermore, our understanding of how and why individuals transition to a chronic pain state after an acute insult is limited. Research to address these issues conducted by interdisciplinary and multidisciplinary research teams is strongly encouraged, as is research from underrepresented, minority, disabled, or female investigators.

BACKGROUND

Pain is a critical national health problem. It is the most common reason for medical appointments and costs this country over $100 billion each year in health care and lost productivity. Chronic pain affects more than 50 million Americans per year. Pain often results in disability and, even when not disabling, it has a profound effect on the quality of life. Its deleterious effects have been demonstrated in morbidity, immune function, sleep, cognition, eating, mobility, affective state, psychosocial behaviors, and overall functional status. In the hospitalized patient, pain may be associated with increased length of stay, longer recovery time, and poorer patient outcomes, which in turn have health care quality and cost implications.

The NIH Pain Consortium was established in 1996 to enhance pain research and promote collaboration among researchers across the many NIH ICs that have programs and activities addressing pain. Currently, the research interests of twenty-one NIH Institutes, Centers, and Offices are represented in the Consortium. Although these combined efforts have resulted in great scientific progress, the understanding and treatment of pain remains incomplete. Congress declared 2001 to 2010 the Decade of Pain Control and Research. NIH continues to be responsive to and in alignment with the focus of this declaration. At the Annual NIH Pain Consortium Symposia, "Advances in Pain Research," speakers present new pain research findings and reiterate the need for an ongoing multidisciplinary research agenda that will lead to the prevention or effective treatment of unwanted pain.

The NIH Pain Consortium supports research on all conditions in which pain is a prominent feature. Of interest are diseases, such as cancer, that of themselves or their treatment may result in pain. Many primary conditions, whether acute (such as injury), recurring (such as migraine), or chronic (such as arthritis) are significantly complicated by co-morbid pain disorders. Some pain conditions are unassociated with other primary diagnoses. Chronic pain is widely believed to represent a disease itself, causing long-term detrimental physiologic changes and requiring unique assessments and treatments. The areas of research detailed below and the following acute and chronic pain conditions are of special interest but do not comprise a comprehensive or complete listing of research areas relevant to this FOA.

New and innovative advances are needed in every area of pain research, from the microperspective of molecular sciences to the macro perspective of behavioral/social sciences. Although great strides have been made in some areas, such as the neural pathways of pain, chronic pain and the challenge of its treatment have remained uniquely individual and largely unsolved. Proposals that seek to improve the understanding of the causes, costs, and societal effects of both acute and chronic pain and the relationships between the two are highly encouraged. Studies on the mechanisms underlying the transition from acute to chronic pain are also needed. Additionally, proposals that link such understandings to the development of better approaches to therapeutic interventions, including complementary and alternative medicine (CAM) interventions, and management of acute and chronic pain are in keeping with the current translational focus of NIH and are encouraged.

The following topicareas are not intended to be comprehensive or exhaustive. Synergistic studies that reach across two or more of these areas are encouraged. Interdisciplinary and multidisciplinary research is especially encouraged, as is research that involves specific cooperation between basic and clinical scientists. These pain research areas also cut across ICs and programs and should not be viewed as restricted to only one specific IC.

MOLECULAR AND CELLULAR MECHANISMS OF PAIN

Improved treatments of acute and chronic pain conditions require a thorough understanding of the processes underlying the transmission and perception of painful stimuli. Discovery of the molecules, cells, and neuronal pathways involved in nociception/pain perception and affective aspects of pain are critical. Molecular and cellular studies, when coupled with studies in animal models and clinical research, will provide a comprehensive basis for the development of new pharmacological, behavioral, and technology-based treatments for chronic pain disorders, and/or research on the mechanisms of action of therapies effective for chronic pain. Hormones, neurotransmitters and their receptors, ion channels, G-protein coupled receptors, neuropeptides, and neurotrophic factors are just a few of the molecules of interest in pain studies. Molecular mechanisms and nervous system circuitry involved in facilitation and inhibition of pain signaling and in the development of hypersensitive pain states are important targets of pain research. Neurons, glial cells, and keratinocytes all play important roles in pain sensation and approaches examining their individual functions and their interactions are vital for understanding pain processes. Research is encouraged but not limited to science in the following areas:

Molecules and processes that target cellular mechanisms involved in signaling, modulation, and perception of pain, as well as changes in these processes over the developmental life-course, to enhance innovative therapeutic development.

Ontogeny and neuropharmacology of the pain system.

Endogenous and environmental factors that alter pain during the course of development, in response to injury, and related to disease processes.

Mechanisms of hypersensitivity including both central and peripheral mechanisms of hyperalgesia and allodynia.

Clinical studies have identified polymorphisms at several gene loci that are associated with differential sensitivity to experimental pain. Inbred strains of mice also show differential pain responses in models of neuropathic and inflammatory pain. These studies strongly suggest that genetics plays an important role in pain mechanisms. Chronic pain conditions are complex disorders where environmental and genetic influences interact to affect sensitivity to noxious stimuli and relief from pain. Polymorphisms and mutations in mitochondrial DNA may also play a role in modulating pain, especially in muscles and peripheral nerves. Elucidating the genetic contributions to the individual variability in pain sensitivity and perception is of much interest. Research is encouraged but not limited to science in the following areas:

Genes and gene variants involved in the complex processes of pain perception.

Utilization of pharmacogenetics to identify gene variants with potential to inform treatment providers which pain medications may be most effective for the individual needing therapy, with the fewest side effects.

Use of gene therapy to ameliorate chronic pain.

Gene polymorphisms and gene-environment interactions that predict pain development or treatment response.

Epigenetic mechanisms underlying chronic pain conditions.

BIOBEHAVIORAL PAIN

The experience of pain is a complex interaction of biological, cognitive, behavioral, sociocultural, spiritual, and environmental factors. Pain etiology, severity, tolerance, exacerbation, maintenance, and treatment are all significantly influenced by this complex of acknowledged but poorly understood interactions. Comorbid conditions that alter affect, such as mood disorders, can induce or exacerbate pain. Although it is recognized that psychological factors, such as expectation or stress, significantly contribute to pain tolerance and treatment efficacy, the physiological mechanisms of these effects are poorly understood. Physiologic responses such as autonomic arousal, muscle tone and activity, skin thermal receptor activation, and cardiopulmonary reactivity, are perceived as painful in some behavioral and sociocultural environments, but not in others. The elucidation of these complex interactions will enable better assessment of pain in clinical settings, more effective therapeutic approaches, greater ability to prevent pain onset, and potentially will increase the individual's ability to self-manage pain.

Research is encouraged but not limited to science in the following areas:

Adaptation to pain and ways to incorporate this adaptation into treatments.

Mechanisms and process variables that are responsible for the efficacy of behavioral and CAM interventions for pain. This research includes studies to better understand the effect of patients' expectations and beliefs, psychophysiological states (e.g., anxiety, relaxation, stress), adherence, and specific cognitive (e.g., imagery) and sociocultural (e.g., support systems) components in behavioral and CAM interventions to treat pain.

Sensory, cognitive, and affective aspects of acute and chronic pain in individuals across the developmental lifespan.

Development of methods for assessing relative contributions of biological, psychological, behavioral, and environmental predictors of the course of pain, pain dysfunction, and response to treatment for pain.

Interactions of pain and sleep, their combined impact on function and illness recovery, and interventions that target these interactions.

Relationships among a variety of emotional states (e.g., anger, fear, anxiety and depression), which are associated with acute and chronic pain conditions, and how these affective states modify the experience of pain and treatment outcomes.

Mechanisms that underlie gender and cultural differences in the pain experience.

MODELS OF PAIN

There are many factors responsible for pain experienced by patients. Current animal models of pain have been useful in understanding the mechanisms of pain and developing interventions that target these particular mechanisms. However, many of the existing animal models do not adequately reflect clinical pain conditions and, in particular, chronic pain disorders. The development of new animal models is necessary in order to discover the underlying mechanisms of pain perception as well as the mechanisms of analgesia that will prove useful in treating patients. Innovative clinical modeling studies are also needed to advance our understanding of these underlying mechanisms. Research is encouraged but not limited to science in the following areas:

New animal models and refinement of existing animal models.

New measures of pain in animals that are non-invasive and objective, and that permit a behavioral or functional assessment of pain and pain treatment outcomes.

Use of transgenic animals in the study of pain mechanisms.

Studies in patients with chronic pain conditions that develop, test, and validate new models of these chronic disorders.

Computational models that predict development of pain and/or treatment responses.

Computer simulations of pain that overcome ethical concerns and expand the range of studies possible.

Most healthcare system interactions are initiated by persons with complaints of pain. To date, direct patient report is the basis of most pain assessments. Yet many patients, including the very young, persons with cognitive, sensory, psychiatric, or physical disabilities, those rendered unresponsive by their physiologic state (e.g., drug intoxication, severe brain injury), and those persons who by culture, education, language, or communication skills may be unable to effectively respond using currently validated assessment tools. To study, model, predict, prevent, diagnose, treat, or manage pain effectively, sensitive multimodal measurement tools are needed. Pain assessment techniques must be valid and reliable and provide sensitivity, both with single and repeated measurements, and allow for the assessment of acute, chronic, persistent, and breakthrough pain. Severity/intensity, type/location/source (i.e., somatic, visceral, neuropathic), and duration (acute, chronic, persistent, breakthrough) are key components to assess. Assessment should include diagnostic as well as outcomes measures. Research is encouraged but not limited to science in the following areas:

Refinement of existing physiologic techniques for measuring pain for greater sensitivity and specificity.

Refinement of pain measurements that can account for or predict the trajectory or course of pain, as well as the changes in pain over time.

Predictive biomarkers of pain that are sensitive to rapid changes in pain.

Develop pain assessments that are sensitive across both developmental and cognitive spectrums, especially assessments of pain in children and in older adults with declining cognitive function.

New technologies to improve pain assessment in all populations, but especially in those persons with limited language abilities.

PAIN MANAGEMENT

The prevalence of pain and inadequate pain management in patients is well documented. It is estimated that 75% of patients with advanced cancer experience moderate to severe pain; an IOM report states that 40% of people at the end of life have severe, unrelieved pain. A number of advances have been made in the treatment of chronic pain, most notably the neuroactive medications, counter-stimulation methods, and cognitive-behavioral therapies. However, adoption of these advances remains modest. Many patients report that they are reluctant or afraid to report their pain, are unaware of available pain management modalities, or do not adhere to pain treatment when available. Healthcare providers undertreat pain, fearing patient addiction, drug interactions, or adverse events. In addition, research findings consistently show the heterogeneity of response to treatment, even for pain of the same type and etiology.

Due to the biobehavioral nature of pain, pain management should engage interdisciplinary teams and involve both pharmacologic and non-pharmacologic approaches. Research is encouraged but not limited to science in the following areas:

Models of therapy in those with uncontrolled pain and/or breakthrough pain.

Pain management strategies at the end of life.

Long-term (i.e., physiologic, behavioral, or developmental) effects of pharmacologic treatment during the neonatal period and childhood.

Clinical trials to establish best pain management practices.

EPIDEMIOLOGY OF PAIN

One goal of this FOA is to stimulate innovative investigations that enhance our understanding of the incidence, prevalence, and correlates of pain within and across populations. Epidemiology is one of the fields of science recognized for its contribution to understanding of physical and mental disorders. However, epidemiologic information concerning pain disorders is not well developed. Research is encouraged but not limited to science in the following areas:

Incidence and natural history of pain disorders and their correlates over time.

Interplay of environmental (e.g., familial and/or neighborhood quality and resources), physical (e.g., co-morbid medical disorders that are a result of, or a cause of pain), behavioral (e.g., co-morbid mental and substance use disorders), and social or socio-economic (e.g., loss of employment-including issues of secondary or tertiary gain, social isolation, lack of mobility, dependence on others for basic caretaking) factors.

Risk factors; including age, ethnicity, family history, gender, genetic predisposition, lifestyle, occupation, pre- or co-existing mental and physical disorders, and socio-economic status (SES); and the mechanisms that are associated with the occurrence, maintenance, and remission of pain conditions.

Impact of pain on an individual's SES and the resulting health consequences (e.g., obesity, deconditioning, mental disorders, substance abuse) controlling for the effect of the cultural and socio-economic influence of the community.

Prevalence of and methods for self-management of pain within and across cultural, racial, ethnic populations, and populations of special interest such as persons with disabilities, across developmental age groups.

The effect changes in practice or policy have on the measures of pain, e.g., effect of the increase in the amount of opioid prescriptions on the natural course of pain using aggregate population measures.

Creation and adoption of innovative epidemiologic and statistical methodologies and study designs to further the understanding of pain disorders. Also use these techniques to maximize the analytic yield from new and existing data sets.

Co-morbid disorders and pain, including descriptive studies of risk and protective processes, and interventions aimed at relieving adverse consequences associated with co-morbid disorders and pain.

HEALTH DISPARITIES

The Institute of Medicine reported significant racial and ethnic disparities with regard to the socioeconomic, health, and quality-of-life impacts of pain. Racial and ethnic minorities tend to be under treated for pain when compared with non-Hispanic Whites. There is also evidence for racial/ethnic differences in pain care for various types of pain. Persons with disabilities report greater levels of pain and less benefit from treatment than do those without disabilities. Little other data exists as to pain disparities in persons with disabilities, the homeless, or persons living in frontier/extremely rural areas. It is clear that many factors contribute to these health disparities, including patient preferences, differences in attitudes toward and response to treatments, access to and accessibility of health care providers, and health care system factors. This program announcement invites research applications that seek to address the underlying causes of these disparities and suggest ways to address and remedy them. In particular, clinical investigations and appropriate clinical trials relevant to health disparity issues are of interest. Research is encouraged but not limited to science in the following areas:

Differences in care for various types of pain, acute postoperative pain, treatment-related pain, cancer pain, or chronic non-malignant pain, in various settings (i.e., health clinics, physician and dental offices, institutional settings including long-term care facilities, assisted living facilities, or emergency departments), and management of pain at the end of life.

Measures of pain perception for those with cognitive impairment, or limited health literacy and from varied cultures.

Assessment of the global impact, including societal and medical consequences, of pain related disparities on both individuals and society, and the potential impact of pain-related disability.

Diverse cultural beliefs about and actions taken for pain and its management including self-care and that of lay caregivers.

Treatment and management strategies for chronic pain in diverse populations.

Means to identify population differences in pain perception and processing by addressing the incidence, severity, and consequences of pain in these and the general populations, and in specific disease states.

New diagnostic tools for different pain mechanisms, and objective measures of treatment response that have validity in diverse populations.

The prevalence and effectiveness of the use of non-pharmacological and novel (e.g. virtual reality) therapies for pain treatment in diverse populations such as ethnic minority groups and persons with disabilities.

The translation of laboratory-based, scientific discoveries into practical, clinical applications is a current priority for NIH. Such translational research has a reasonable probability of leading to practical outcomes within the foreseeable future and likewise resultant clinical findings should stimulate new areas of basic research. Inherent in translational research is the recognition of both efficacy (i.e., does the intervention work in a controlled setting) and effectiveness (i.e., does the intervention work in the natural environment) research. Effective translational research is extremely important in pain research and is needed to bridge the inherent differences in approach between basic studies of pain and the clinical study of pain conditions. Accordingly, proposals directed toward translational pain research are of particular interest. Research is encouraged but not limited to science in the following areas: